February 13–16, 2017



HIV More Than Doubles Odds of Cerebral Small-Vessel Disease in French Study
CROI | February 13-16, 2017

Mark Mascolini

Prevalence of cerebral small-vessel disease (CSVD) stood at 52% in a French analysis of people over 49 years old who had well-controlled HIV infection [1]. Compared with an HIV-negative group, people with HIV had more than twice higher odds of CSVD.

French ANRS researchers noted that CSVD causes "substantial cognitive, psychiatric, and physical disabilities" in older people, contributing to about 20% of strokes and 45% of dementias. Older age, hypertension, smoking, and substance use all boost CSVD risk. HIV also appears to heighten the risk of CSVD, probably through ongoing inflammation. But sorting out the impact of HIV alone on CSVD risk has proved difficult because HIV populations typically have major CSVD risk factors. Also, studies of CSVD in people with HIV have been small or inadequately controlled.

The ANRS team focused on people at least 50 years old who had HIV for at least 5 years. Everyone was taking antiretroviral therapy and had a viral load below 50 copies and a CD4 count at or above 350. The researchers excluded people who used illegal drugs or had prior stroke or transient ischemic attack, neurologic AIDS, or certain other CSVD risk factors. As in other CSVD studies, they used MRI scans to identify CSVD. They planned the study to detect a difference of 7.5% in CSVD prevalence in people with versus without HIV.

The analysis included 456 people with HIV and 154 HIV-negative controls. The HIV group was significantly younger than the HIV-negative group (median 56 versus 58, P = 0.0094), had a significantly higher proportion of men (85% versus 77%, P = 0.0302), and had a significantly higher proportion of regular alcohol drinkers (7% versus 3.9%, P = 0.0001). Substantial proportions of the HIV group (29%) and the HIV-negative group (42%) were older than 60. HIV-positive participants had a higher proportion with hypertension (33% versus 21%, P = 0.004), high cholesterol (41% versus 19%, P < 0.0001), high triglycerides (22% versus 6%, P < 0.0001), and a history of cardiovascular disease (13% versus 5%, P = 0.0093).

Among people with HIV, 67% were men who have sex with men, median nadir and current CD4 counts stood at 196 and 655, and median time on antiretroviral therapy measured 17 years.

Just over half of people with HIV, 52%, had MRI-determined CSVD, compared with 36% of HIV-negative people. Respective proportions with severe CSVD were 19% and 14%. Logistic regression analysis adjusted for age, gender, alcohol use, hypertension, high cholesterol, high triglycerides, and cardiovascular disease history determined that the HIV group had twice higher odds of CSVF (adjusted odds ratio [aOR] 2.3, 95% confidence interval [CI] 1.5 to 3.6). There was a trend toward 60% higher odds of severe CSVD with HIV (aOR 1.6, 95% CI 0.9 to 2.8).

In the HIV and non-HIV groups, CSVD prevalence stood at 35% and 9% in 50- to 54-year-olds, 52% and 23% in 54- to 60-year-olds, and 69% and 64% in people over 60 years old. In adjusted analyses, CSVD risk conferred by HIV diminished with age: aOR 5.2 in the 50-to-54 group, aOR 3.7 in the 54-to-60 group, and aOR 1.2 (not significant) in the over-60 group. The researchers attributed this lack of an association in the oldest group to the competitive risk of dying for older people in this cross-sectional analysis.

Among people with HIV, five factors independently predicted CSVD: being a non-MSM male (aOR 2.22), age 54 to 60 (aOR 2.08), age over 60 (aOR 4.04), hypertension (aOR 1.76), and nadir CD4 count below 200 (aOR 1.53). The ANRS team is assessing potential associations between markers of inflammation and immune activation and CSVD risk.

The researchers stressed that classic risk factors--older age and hypertension--as well as low nadir CD4 count predicted CSVD in people with HIV. They proposed that clinicians and HIV-positive people "should identify and control vascular disease risk factors, such as smoking and hypertension, and should continue to be vigilant for symptoms of CSVD."

Moulignier A, Savatovsky J, Godin O, et al. Cerebral small-vessel disease in HIV-infected patients well controlled on cART. Conference on Retroviruses and Opportunistic Infections (CROI), February 13-16, 2017, Seattle. Abstract 75.